An organization tool to enhance work motivation - part I.

Increasingly, physicians, in both primary care and specialties, are gathering together into partnerships, single or multispecialty group practices, corporations, and HMOs. Many of physicians are becoming salaried employees of these organizations. As this trend increases, the physician, once pictured as an autonomous entrepreneur and decision-maker, is giving way to the salaried physician-employee, subject to the management and hierarchical structure of organizations. In the first of two articles, the author lays the background for the need for job satisfaction surveys of salaried physicians.

Recent forecasts predict that the nation as a whole will have a considerable surplus of physicians in many specialties. As competition among physicians grows, more physicians will consider group practice an ideal arrangement to reduce risk and satisfy life-style desires. In addition, a group has the ability to market a physician's services and can better acquire human resources, capital, and practice supplies. Employment often provides new physicians with a ready-made practice, thereby saving practice start-up costs and allowing them to pay off their acquired debts more rapidly. An increasing number of residents also lack knowledge of how to establish and manage a successful solo practice.[1]

With more physicians anticipated to be employees, health care organizations must sustain job satisfaction among this group to achieve continuity and stability, as well as high productivity and patient satisfaction. Health care managers and medical directors must make themselves aware of the factors that influence physician professional behavior. Physician employers must consider work motivational strategies in relationship to these once autonomous professionals.

Work Motivation Theories

Considerable research has been directed toward motivation and interpersonal strategies that enhance working conditions. Maslow's hierarchy of needs is familiar to most managers.[2] Ascending through biological needs to security and safety needs to social needs, a person is then concerned about self-esteem, independence, self-actualization, and recognition. This also applies to the workplace. Once a salary reaches a level to pay for food, housing, and social class, the worker looks to achievement, autonomy, psychological growth, and personal advancement to produce job satisfaction. Frederick Taylor's system of "scientific management" assumed that workers could only be motivated to increase productivity in return for financial rewards.[3]

Hackman and Oldham developed the Job Diagnostic Survey to study the affective reactions of employees to their job and work settings and how job design affects work motivation and productivity.[4] They hypothesized that:

MPS = (SV + TI + TS) x A x F
          3
MPS = Motivating Potential Score
SV = Skill Variety
TI -- Task Identity
TS = Task Significance
A = Autonomy
F = Feedback

Skill variety is the degree to which the job requires the individual to perform a wide range of tasks. Task identity is the degree to which the job requires the completion of a whole piece of work that employees can identify as resulting from their individual efforts. Task significance is the degree to which the job is seen as having an impact on the lives or work of other people. Autonomy is the degree to which employees have discretion in determining work schedules and procedures. Feedback is the degree to which the job provides employees with clear and direct information about job performance. These factors lead to an experience of meaningfulness of work, a personal responsibility for the outcome of work, and a knowledge of the actual results of work activities. These conditions promotes high internal work motivation, high-quality work performance, low absenteeism and turnover, and high satisfaction with work.

Other Work Motivation Theories

The nature of meaningful work was a primary concern of Frederick Herzberg,[5] a noted industrial psychologist. His behavioral studies led him to his "motivation-hygiene theory." He asked workers to describe when they felt exceptionally good and bad about their jobs. He found that most workers had good or satisfied feelings related to their actual job content or work experience. This included individual achievement, responsibility, recognition, advancement opportunity, and rewards from the work itself. These growth or "motivational" factors were intrinsic to the job.

His worker avoidance or "hygiene" factors, causing dissatisfaction, were extrinsic to the job content. These bad or dissatisfaction feelings were most often related to surrounding or environmental aspects of work. These context factors include company or administrative policies, supervision, physical facilities of the workplace, the quality or quantity of resources to accomplish the job, interpersonal relationships with other staff, salary, and personal life issues. When this "motivation-hygiene" theory is applied to health care organizations, one begins to have a clearer picture of what are satisfiers and dissatisfiers for these providers.

Work or Job Satisfiers

Satisfiers effectively stimulate employees to greater performance and productivity. Achievement refers to the satisfaction of completing a job, solving a problem, and seeing results. In medicine, this is making the diagnosis, prescribing the treatment, and doing the follow-up while meeting the patients' medical care needs. It is the challenge of curing ill patients or screening for disease. That is why we return to work each day.

Recognition is a reward for a job well done. Responsibility and authority

refer to the employee's control over the job and perhaps over the work of others. Advancement is upward mobility, including status, money, and authority. Growth involves learning new skills, new therapies, the latest medical advance in one's particular specialty, the newest technology, there-by expanding work significance.

Work or Job Dissatisfiers

In contrast, context or environmental factors causing dissatisfaction with jobs include administrative policy, management or supervision, working conditions, interpersonal relations, amount of salary paid, job security, one's age or individual health, and characteristics of one's personal life. Feelings about adequacy or ineffectiveness of the organization or management at one's workplace, one's willingness to cooperate with supervision, and a sense of fairness within the organization are all important to job performance and are never perfect. Working conditions include the quantity of work and the facilities and resources available to do the work--pleasant decorations, professional instruments, or human support staff. Salary includes all types of compensation, benefits, and bonuses. Job security can be determined by objective signs, such as longevity rewards, tenure, pension, and organizational stability.

Job satisfaction is also described as the difference between work expectation and the actual job experience. This is part of Locke's needs fulfillment theory, where there may be a perceived discrepancy between what an individual worker wants or values and what is received.[6] This can be maximized through proper orientation and training programs.

Physician Satisfaction Surveys

One of the first surveys measuring the job satisfaction of physicians in organized settings was made by Richard Lichtenstein on prison physicians in 1984.[7] There had been many descriptive studies of physicians before that time, but none of salaried physician employees. Medicoeconomic journals and medical group associations regularly published satisfaction surveys. Many demographic studies of physicians by the American Medical Association and other medical societies included satisfaction-type questions. Some large group practices in the late 1980s began to use general staff satisfaction surveys as managerial tools to make changes not only to enhance the satisfaction of their health care providers but also to increase efficiency and productivity. The goal was to reduce turnover and to design incentive programs to promote job and professional satisfaction.

Traditionally, physicians seemed above this type of survey; they were viewed as employers and owners of the health care industry. But, because more and more physicians were joining organizations and professional corporations, research applying organization behavior theory to medical care providers is becoming necessary.

Professional Life Influences

Physicians are professionals. They have been trained to be experts. Within an organization, be it the small private office, a hospital, or a group practice, the fact that physicians are professionals affects how they think about themselves.

A professional serves the welfare of the client or the patient as a first-order goal--at least equal to serving the organization. Professionals follow a code of ethics monitored and enforced by peers. Thus, they are responsible to professional colleagues as well as to the leaders of their medical organizations. They value autonomy and the ability to practice their profession subject to goals and conditions they set for themselves, not what others tell them to do. They wish to treat the individual patient and do not want to be subject to external influences. Thus, physicians naturally resist efforts of third-party payers to impose prior authorization requirements, when the physician has made the decision that the service is necessary for the benefit of the patient.

Physician are taught the value of autonomy. Their knowledge and skills are their source of power when dealing with those outside the profession. They are the professional authority in the doctor-patient relationship. Many physicians feel they should control the delivery of medical service because they deliver the professional services, about which they are experts.

As in every other profession, physician make use of resources. They have a technological imperative imposed on them by society to deliver the best quality of medical care. Nursing services, secretaries, medical record personnel, answering services, laboratories, and pharmacies are all extenders of physicians' goal of healing. Office space, equipment, specialty, and geographic location all characterize individual physicians, but the goal of personal and individual health care for their patients is common to all physicians. Physicians' satisfaction with their work is likely to depend on the extent to which they are able to practice without having to worry about the availability of patients, good support staff, the adequacy of facilities, or financial reimbursement.

Inevitably, health care organizations grow and have goals of their own. Managers and administrators are hired to facilitate these goals. Physician may head or own these organizations, but, at times, the complexity of getting to a organizational goal comes in conflict with the goals of the individual medical professional. Implicit in the focus of professional autonomy is the likelihood of conflict with the authority structure of the bureaucratic organization in which the professional works. Increasingly, one of these areas is the control of medical services delivery.

The goals of the organizations that physicians find themselves employed in may dovetail or may counteract the professional goals of individual physicians. Thus, it is imperative for organizations to begin to consider factors that lead to satisfaction or dissatisfaction in order to facilitate the physician's ability to continue to provide high-quality medical care.

Areas of Satisfaction Survey Inquiry

Several instruments have been used to survey physicians' satisfaction with their jobs in health care organizations: Konrad's Survey of Salaried Physicians by the Health Care Research Center, North Carolina University at Chapel Hill[8] Davidson's Harvard Community Health Plan Study of Physician and Management[9]; Silversin's AMICUS surveys from the Fallon Clinic, Inc., Worcester, Mass.[10]; and Stamps and Piedmonte's Index of Work Satisfaction Scale.[11]

Questions relating to physician job satisfaction fall into seven distinct categories:

Job Satisfiers:

* Clinical work.

* Professional career goals.

Job Dissatisfiers:

* Financial compensation.

* Administrative or management issues.

* Colleague interaction.

* Clinical resources (facilities, equipment, and support staff).

* Personal time.

Clinical Work

Many questions dealt directly with clinical work or direct patient contact. They centered on the immediate patient-physician relationship. Questions indicated whether there was adequate time to spend with patients; the manageability of the patient work load; the amount of paperwork or documentation; scheduling of hours and appointments; clinical decision making; and use of clinical protocols, guidelines, or algorithms for patient care. Was the physician able to practice the desired type and specialty of medicine, and did the physician perceive that he or she was practicing good quality medical care?

Professional Career Goals

The degree of professional autonomy, the organization's recognition of them beyond salary, respect from the patients, and opportunities for advancement through continuing medical education or professional development are all important to fulfilling physician career goals.

Financial Reward

Salary, bonus, shareholder status, and benefits, including pension, are all compensation rewards.

Administration Issues

Communication with management, whether physician or nonphysician, is important for professional fulfillment. This category includes orientation, knowledge of the objectives and goals of the organization, the degree of direct supervision, and regular feedback. A perception of satisfaction with management usually leads to trust, pride, and high morale, while dissatisfaction leads to frequent turnover, conflict, and lowered productivity. An organization's interest in physicians' satisfaction is also important. Tenure and seniority promote job security, which is important to the professional, and a pension from the organization ensures it. Questions concerning loyalty or pride in the organization are often asked in this category.

Colleague Interaction

Physicians' ability to relate to colleagues and others in the organization, the degree of teamwork, the ease of referral among colleagues, and the opportunity to discuss cases enhance the social aspects of the job. Ongoing professional education is also available through collegial relationships.

Resources

An adequate number of qualified support staff (nurses, secretaries, medical record librarians, lab or x-ray technicians, telephone operators, or dictation) is essential to the smooth workings of a health care organization. The quality of physical facilities and the environment, the privacy of a consulting office or examination room, and a pleasant waiting room may be thought to be amenities, but they are very important to physician productivity, effectiveness, and efficiency in patient care. Proper equipment, specific to the specialty and technologically current, is necessary for physicians to feel that they provide high-quality medical care.

Personal Time

Depending on marital status, health, place in the professional life cycle, hobbies, and age of children, perceived interference of the job with personal and family time, aside from what is happening on the job directly, may lead to job dissatisfaction. Lack of time off or vacations rapidly leads to burn-out.

Summary

There is no question that health care organizations, especially group practices, need to pay attention to job satisfaction on their professional staffs. Physicians need to be surveyed regularly for areas where management might enhance work satisfaction. With professional job satisfaction surveys, managers have a tool to study the needs of their professional staff. Through strategic planning, management can facilitate job satisfaction, offer "job enrichment," maintain productivity, ensure high-quality service, avoid burn-out, and reduce turnover.

References

1. Kronhaus, A. Choosing your Practice. New York, N.Y.: Springer-Verlag, 1990.

2. Maslow, L. Motivation and Personality. New York, N.Y.: Harper and Row, 1954.

3. Taylor, F. Principles of Scientific Management. New York, N.Y.: Harper, 1911.

4. Hackman, R., and Oldham, G. "Development of the Job Diagnostic Survey." Journal of Applied Psychology 60(2): 159-70, April 1975.

5. Herzberg, F. "One More Time: How Do You Motivate Employees?" Harvard Business Review 65(5):109-20, Sept.-Oct. 1987.

6. Locke, E. Handbook of Industrial and Organizational Psychology. Chicago, Ill.: Rand McNally, 1976.

7. Lichtenstein, R. "Measuring the Job Satisfaction of Physicians in Organized Settings." Medical Care 22(1):56-68, Jan, 1984.

8. Konrad, T. "The Salaried Physician: Medical Practice in Transition." Unpublished paper. Health Services Research Center, University of North Carolina, Chapel Hill, 1989.

9. Davidson, S. "Role of Management in Ambulatory Care Outcomes." Grant application to Harvard Foundation, Boston, Mass., 1990.

10. Silversin, J. AMICUS, 2067 Massachusetts Ave., Cambridge, Mass., 1990.

11. Stamps, P., and Piedmonte, E. Nurses and Work Satisfaction. Ann Arbor, Mich.: Health Administration Press, 1986.

Further Reading

The following additional sources of information on physician job satisfaction were obtained through a computerized search of databases. Copies of articles are available from the College for a nominal charge. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813/287-2000.

Linn, L., and others. "Work Satisfaction and Career Aspirations of Internists Working in Teaching Hospital Group Practices ." Journal of General Internal Medicine 1(2):104-8, March-April 1986.

Pasternak, D., and others. "Physician Satisfaction in Group Practice: A Comparison of Primary Care Physicians with Specialists." GHAA Journal 7(1):50-9, Spring 1986.

Petrozzi, M,, and others, "Clinical Activities and Satisfaction of General Internists, Cardiologists, and Ophthalmologists." Journal of General Internal Medicine 7(3):363-5, May-June 1992.

Schulz, R., and others. "Physician Satisfaction in a Managed Care Environment." Journal of Family Practice 34(3):298-304, March 1992.

Stamps, P., and others. "Measurement of Work Satisfaction among Health Professionals." Medical Care 16(4):33752, April 1978.

R.F. Pagano, MD, MBA, is in Pediatric practice at Fallon Clinic, Worcester, Mass, and is on the Board of Directors of Fallon Community Health Plan. She is a member of the College's Forum on Woman in Medicine and Management.